Section 1905(a)(28) ATTACHMENT 3. 1- A

Attachment# 25

Page 1

FREESTANDING BIRTHING CLINICS

a) Licensed or Otherwise State-Approved Freestanding Birth Centers

Provided: No limitations X With limitations _ None licensed or approved

Please describe any limitations:

Birthing center maternal patients shall be limited to women initially determined to be at lowmaternity risk and evaluated regularly throughout pregnancy to ensure they remain at low risk fora poor pregnancy outcome.

b) Licensed or Otherwise State- Recognized covered professionals providing services in theFreestanding Birth Center

Provided: No limitations X With limitations (please describe below)

Not Applicable( there are no licensed or State approved Freestanding BirthCenters)

Please describe any limitations:

Must be licensed in the State of Utah to provide such services.

Please check all that apply:

X ( a) Practitioners furnishing mandatory services described in another benefit category andotherwise covered under the State plan ( i. e., physicians and certified nurse midwives).

b) Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum carein a freestanding birth center within the scope of practice under State law whose servicesare otherwise covered under 42 CFR 440.60 (e.g., lay midwives, certified professionalmidwives ( CPMs), and any other type of licensed midwife).

c) Other health care professionals licensed or otherwise recognized by the State toprovide these birth attendant services (e. g., doulas, lactation consultant, etc.).*

For( b) and ( c) above, please list and identify below each type of professional who will beproviding birth center services:

T.N. # 13- 015 Approval Date

Supersedes T. N. # 12- 018 Effective Date 7- 1- 13

Section 1905(a)(28) ATTACHMENT 3. 1- B

Attachment# 25

Page 1

FREESTANDING BIRTHING CLINICS

a) Licensed or Otherwise State-Approved Freestanding Birth Centers

Provided: No limitations X With limitations _ None licensed or approved

Please describe any limitations:

Birthing center maternal patients shall be limited to women initially determined to be at lowmaternity risk and evaluated regularly throughout pregnancy to ensure they remain at low risk fora poor pregnancy outcome.

b) Licensed or Otherwise State-Recognized covered professionals providing services in theFreestanding Birth Center

Provided: No limitations X With limitations ( please describe below)

Not Applicable( there are no licensed or State approved Freestanding BirthCenters)

Please describe any limitations:

Must be licensed in the State of Utah to provide such services.

Please check all that apply:

X ( a) Practitioners furnishing mandatory services described in another benefit category andotherwise covered under the State plan ( i. e., physicians and certified nurse midwives).

b) Other licensed practitioners furnishing prenatal, labor and delivery, or postpartum carein a freestanding birth center within the scope of practice under State law whose servicesare otherwise covered under 42 CFR 440.60 (e.g., lay midwives, certified professionalmidwives ( CPMs), and any other type of licensed midwife).

c) Other health care professionals licensed or otherwise recognized by the State toprovide these birth attendant services (e. g., doulas, lactation consultant, etc.).*

For( b) and (c) above, please list and identify below each type of professional who will beproviding birth center services:

T.N. # 13- 015 Approval Date 7Z= 3

Supersedes T. N. # 12- 018 Effective Date 7- 1- 13

42 CFR ATTACHMENT 4. 19- B

440.90 Page 12a

L. CLINIC SERVICES (Continued)

1. Dialysis Clinics— Payment for renal dialysis is based on the established fee schedule

unless a lower amount is billed. The amount billed cannot exceed usual and customarycharges. Fees are based on the Medicare payment in Salt Lake County for dialysis.

Except as otherwise noted in the plan, state developed fee schedule rates are the same forboth governmental and private providers. The agency's rates were set as of July 1, 2013,and are effective for services on or after that date. Fee schedule payments are based onthe established fee schedule unless a lower amount is billed. All rates are published on

the agency's website at http!// health. utah. gov/medicaid/.

T.N. # 13- 015 Approval Date

Supersedes T. N.# 12-018 Effective Date 7- 1- 13

42 CFR ATTACHMENT 4. 19- 13

440.90 Page 12b

L. CLINIC SERVICES (Continued)

2. Surgical Centers-- Effective March 1, 2010, payment is based on 66.3 percent of

usual and customary charges and, for specified procedure codes, a fee scheduleestablished from professional judgment, Medicaid historical data, and discounts from

Medicare rates. Effective July 1, 2010, payments will be based on a fee scheduleestablished from professional judgment, Medicaid historical data, and discounts fromMedicare rates.

Except as otherwise noted in the plan, state developed fee schedule rates are the

same for both governmental and private providers. The agency's rates were set as of

July 1, 2013, and are effective for services on or after that date. Fee schedulepayments are based on the established fee schedule unless a lower amount is billed.All rates are published on the agency' s website at http:i/hea)th. utah.gov/ medicaid/.

MULTIPLE AND BILATERAL PROCEDURES

The primary surgical procedure with the highest payment rate is paid based on 100%of the established Medicaid fee. The second highest payment rate is paid based on50% of the established fee schedule. Payment for the other lower payment rates ismade at 25% of the established fee schedule for multiple and bilateral procedures.When CPT modifiers are used, the rate is adjusted for CPT modifiers before thepercentages are applied for multiple units billed for designated procedure codes to payat 100% of the established Medicaid fee schedule.

T. N. # 13-015 Approval Date -

Supersedes T. N. # 12- 018 Effective Date 7- 1- 13

42 CFR ATTACHMENT 4. 19-B

440. 90 Page 12c

L. CLINIC SERVICES (Continued)

3. Alcohol and Drug Clinics -- Payment is based on the established fee schedule unless alower amount is billed. Fees will be set based on historical payments for specificHCPCS codes.

Except as otherwise noted in the plan, state developed fee schedule rates are the

same for both governmental and private providers. The agency's rates were set as ofJuly 1, 2013, and are effective for services on or after that date. Fee schedulepayments are based on the established fee schedule unless a lower amount is billed.

All rates are published on the agency's website at http:// health.utah.gov/ medicaid/.

T. N. # 13- 015 Approval Date z5 3

Supersedes T. N. # 12- 018 Effective Date 7- 1- 13

42 CFR ATTACHMENT 4. 19- B

440. 90 Page 12d

L. CLINIC SERVICES ( Continued)

4. Clinic Services for Physical Therapy and Occupational Therapy- Payments forphysical/ occupational therapy are based on the established fee schedule unless alower amount is billed. Fees are established by discounting historical charge, byprofessional judgment, and by the physical therapy and occupational therapy feeschedule.

Except as otherwise noted in the plan, state developed fee schedule rates are the

same for both governmental and private providers. The agency's rates were set as ofJuly 1, 2013, and are effective for services on or after that date. Fee schedulepayments are based on the established fee schedule unless a lower amount is billed.

All rates are published on the agency's website at httr):// health.utah.gov/medicaid/.

T. N. # 13- 015 Approval Date

Supersedes T. N. # 12- 018 Effective Date 7- 1- 13

Section 1905( a)( 28) ATTACHMENT 4. 19-B

Page 34

FREESTANDING BIRTH CENTER SERVICES

Licensed Birthing Centers -- Payment is based on the established fee schedule unlessa lower amount is billed. The amount billed cannot exceed usual and customarycharges. Fees are based on discounted rates established for physicians.

Except as otherwise noted in the plan, state developed fee schedule rates are the

same for both governmental and private providers. The agency's rates were set as ofJuly 1, 2013, and are effective for services on or after that date. Fee schedulepayments are based on the established fee schedule unless a lower amount is billed.

All rates are published on the agency's website at hftp://health.utah.gov/medicaid/.

T. N. # 13- 015 Approval Date - I d 4

Supersedes T. N. # 12- 018 Effective Date 7- 1- 13